Non-fatal suicidal Non-fatal suicidal behaviour in young behaviour in young

women: links to self-women: links to self-mutilation mutilation

Dr Cate CurtisDr Cate Curtis

ccurtis@waikato.ac.nzccurtis@waikato.ac.nz

Introduction:Introduction:

Although there is an increasing body of Although there is an increasing body of research into youth suicide in New research into youth suicide in New Zealand, much of it is with clinical Zealand, much of it is with clinical populations and quantitative in nature. populations and quantitative in nature. My research was with a community My research was with a community sample of women and focused on finding sample of women and focused on finding out about their perceptions and out about their perceptions and understandings of events. It also understandings of events. It also included interviews with service included interviews with service providers/key informants.providers/key informants.

Areas of discussion will include:Areas of discussion will include:• The relationship between self-The relationship between self-

mutilation and suicidal behaviourmutilation and suicidal behaviour• Survivors’ perceptions of the Survivors’ perceptions of the

services they have encountered and services they have encountered and the recovery process (if time allows)the recovery process (if time allows)

Other key findings included the Other key findings included the importance of sexual abuse as a risk importance of sexual abuse as a risk factor, alongside issues of factor, alongside issues of powerlessnesspowerlessness

Key features of the studyKey features of the study

• Who: 25 women and 25 key Who: 25 women and 25 key informantsinformants

• Where: throughout New ZealandWhere: throughout New Zealand• How: The women were invited to How: The women were invited to

discuss their experiences of becoming discuss their experiences of becoming and being suicidal and recovering and being suicidal and recovering from suicidality. The narratives were from suicidality. The narratives were collated and thematic analysis collated and thematic analysis undertaken. undertaken.

Method: IMethod: I

• Recruitment: class presentations, Recruitment: class presentations, newspaper & magazine articles, word of newspaper & magazine articles, word of mouth.mouth.

• Participants: 25 women who had Participants: 25 women who had engaged in suicidal behaviour while aged engaged in suicidal behaviour while aged under 25. Ages ranged between 21 and under 25. Ages ranged between 21 and 46 at the time of the interview.46 at the time of the interview.

• Procedure: Mostly unstructured Procedure: Mostly unstructured interviews, in person (19). Some by interviews, in person (19). Some by phone (2), email (3), letter (1). Thematic phone (2), email (3), letter (1). Thematic analysis using Nu*Dist.analysis using Nu*Dist.

Literature – self-Literature – self-mutilationmutilation

• Little risk of death, goal of short-term Little risk of death, goal of short-term alleviation through alteration of alleviation through alteration of consciousness. Some overlap with consciousness. Some overlap with suicide attempters (Walsh & Rosen, suicide attempters (Walsh & Rosen, 1988)1988)

• Counter-suicidal (Ross & McKay, 1978)Counter-suicidal (Ross & McKay, 1978)• Secret, most common among Secret, most common among

adolescent females. Sense of relief adolescent females. Sense of relief through endorphin release: self-through endorphin release: self-reinforcing (Alderman, 1997).reinforcing (Alderman, 1997).

• Abuse history very common (Dieter, Abuse history very common (Dieter, Nicholls & Pearlman, 2000).Nicholls & Pearlman, 2000).

•Cognitive distinction between suicide and self-Cognitive distinction between suicide and self-mutilation, though linked to other self-destructive mutilation, though linked to other self-destructive behaviour, e.g. eating disorder (Favazza, 1986, behaviour, e.g. eating disorder (Favazza, 1986, 1996).1996).•Differing levels of depression and suicidal Differing levels of depression and suicidal ideation, attitudes to life (Muehlenkamp, ideation, attitudes to life (Muehlenkamp, Gutierrez, 2004).Gutierrez, 2004).•Dunedin study – most self-harm not suicidal Dunedin study – most self-harm not suicidal

(Shyamala-Rada et al., 2004).(Shyamala-Rada et al., 2004).

Overall: part of the self-harm continuum, quite Overall: part of the self-harm continuum, quite distinct from suicidal behaviour, although some distinct from suicidal behaviour, although some self-mutilators may go on to attempt suicide. self-mutilators may go on to attempt suicide. Links to psychosis, dissociation. Manipulative, Links to psychosis, dissociation. Manipulative, attention-seeking (older lit.).attention-seeking (older lit.).

ResultsResults18 of the 25 had self-mutilated*18 of the 25 had self-mutilated*• Most common forms:Most common forms:• Cutting (14)Cutting (14)• Burning (4)Burning (4)• Hitting/kicking (2)Hitting/kicking (2)• Abrasions (1)Abrasions (1)

• Frequency & duration varied: several Frequency & duration varied: several times a day for several years, to three times a day for several years, to three times in total. Usually several times a times in total. Usually several times a month.month.

* * These results are provided for interest’s sake only.These results are provided for interest’s sake only.

Different from suicide:Different from suicide:• ““Cutting is playing with dying – it’s not Cutting is playing with dying – it’s not

consciously wanting to die…It’s a means of self-consciously wanting to die…It’s a means of self-expression, stress and tension-relief. It made me expression, stress and tension-relief. It made me sane when I was going crazy. It’s not really any sane when I was going crazy. It’s not really any different from smoking or drinking except that it’s different from smoking or drinking except that it’s not socially acceptable.”not socially acceptable.”

• ““Cutting wasn’t a suicide thing, it was a release of Cutting wasn’t a suicide thing, it was a release of emotion. It does hurt, but it doesn’t matter emotion. It does hurt, but it doesn’t matter because you feel like you deserve to hurt. The because you feel like you deserve to hurt. The internal pain is far worse than the physical. internal pain is far worse than the physical. Sometimes cutting could be a way of dealing with Sometimes cutting could be a way of dealing with feeling suicidal, releasing the pain instead of feeling suicidal, releasing the pain instead of making a suicidal act.”making a suicidal act.”

• ““I tried cutting myself on my arm to see what it I tried cutting myself on my arm to see what it would be like to cut my wrists, because I didn’t would be like to cut my wrists, because I didn’t want to fail at a suicide attempt … cutting gave want to fail at a suicide attempt … cutting gave me a sense of release of tension, it changed my me a sense of release of tension, it changed my state.”state.”

Expression of emotions:Expression of emotions:

• “…“…an expression of anger, punishment an expression of anger, punishment for eating [when anorexic]… pressure for eating [when anorexic]… pressure release, a way of relieving suicidal release, a way of relieving suicidal feelings.” feelings.”

• ““Cutting made me feel better for a Cutting made me feel better for a while – it hurt so it felt like a strong while – it hurt so it felt like a strong thing to do, although I knew it was kind thing to do, although I knew it was kind of stupid… It was a clear decision to do of stupid… It was a clear decision to do it, when I felt kind of powerless”it, when I felt kind of powerless”

Fourteen of the 18 women who had Fourteen of the 18 women who had self-mutilated link their behaviour to self-mutilated link their behaviour to sexual abuse:sexual abuse:

““I was unable to express myself, the I was unable to express myself, the [emotional] pain was like a physical [emotional] pain was like a physical ache. I felt raw, as if I’d been peeled. ache. I felt raw, as if I’d been peeled. Cutting provided a release of tension…Cutting provided a release of tension…[the focus on] physical pain made the [the focus on] physical pain made the emotional pain easier to bear.”emotional pain easier to bear.”

““It was because of anger, frustration, inability to It was because of anger, frustration, inability to express my emotions. I had no-one safe to talk to, express my emotions. I had no-one safe to talk to, no-one would understand, I was ashamed, and I no-one would understand, I was ashamed, and I just wouldn’t have been able to bring myself to talk. just wouldn’t have been able to bring myself to talk. I hadn’t even acknowledged it [sexual abuse] to I hadn’t even acknowledged it [sexual abuse] to myself - I kept a very tight lid on my thoughts – so myself - I kept a very tight lid on my thoughts – so how could I talk to anyone about it anyway? It was how could I talk to anyone about it anyway? It was also about proving that I was tough, strong, leave also about proving that I was tough, strong, leave me alone, don’t fuck with me, no-one can hurt me. me alone, don’t fuck with me, no-one can hurt me. Which of course was bullshit. I didn’t hurt because Which of course was bullshit. I didn’t hurt because I didn’t allow myself to feel… at the time I wouldn’t I didn’t allow myself to feel… at the time I wouldn’t have been able to say why I did it. Some-times it have been able to say why I did it. Some-times it was quite public…I guess I was also wanting some-was quite public…I guess I was also wanting some-one to notice and help me, or just give me some one to notice and help me, or just give me some attention, but at the time if any-one had asked what attention, but at the time if any-one had asked what was wrong I probably would have said ‘nothing’.”was wrong I probably would have said ‘nothing’.”

Power and controlPower and control

A key issue, frequently emphasisedA key issue, frequently emphasised• ““I felt absolutely powerless, I I felt absolutely powerless, I waswas

absolutely powerless. My depression absolutely powerless. My depression took a turn I couldn’t control, and I was took a turn I couldn’t control, and I was over the edge…. I felt that nothing was in over the edge…. I felt that nothing was in my control except this aspect of my body my control except this aspect of my body and my life.”and my life.”

• ““I felt mesmerised by the knife and the I felt mesmerised by the knife and the blood, and felt like I was getting a slice of blood, and felt like I was getting a slice of power back.”power back.”

Abuse Abuse sense of sense of externally-targeted externally-targeted attempts attempts successfulsuccessful

powerlessnesspowerlessness to regain sense of control to regain sense of control

no further no further failfail actionaction

self-mutilation toself-mutilation toregain sense of controlregain sense of control

temporarily successfultemporarily successful

sense of powerlessness returnssense of powerlessness returns

suicide attempt / further suicide attempt / further mutilationmutilation

Differences between the Differences between the behavioursbehaviours• self-mutilation began before the first suicide self-mutilation began before the first suicide

attempt, and nearly half continued after the attempt, and nearly half continued after the last suicide attempt; last suicide attempt;

• means used for self-mutilation usually means used for self-mutilation usually different from those used for suicidal different from those used for suicidal behaviour; behaviour;

• participants typically interspersed suicide participants typically interspersed suicide attempts with self-mutilation; attempts with self-mutilation;

• self-mutilation usually occurred more self-mutilation usually occurred more frequently, with several episodes increasing frequently, with several episodes increasing in frequency before culminating in a suicide in frequency before culminating in a suicide attempt; attempt;

• a period of respite from self-harming a period of respite from self-harming behaviours often followed. However, for behaviours often followed. However, for most participants this respite was temporary.most participants this respite was temporary.

Key FindingsKey Findings• Definite relationship, although quite Definite relationship, although quite

distinct behaviours:distinct behaviours:• Goal of self-mutilation: short-term Goal of self-mutilation: short-term

release, to feel better cf not feel at release, to feel better cf not feel at allall

• Change focus of pain to physicalChange focus of pain to physical• PunishmentPunishment• Reclaim control of the bodyReclaim control of the body• Statement of strengthStatement of strength• For most it is physically painful For most it is physically painful

• However, participants brought up the However, participants brought up the topic of self-mutilation without prompting topic of self-mutilation without prompting and made clear links between self-and made clear links between self-mutilation and suicide attempts, mutilation and suicide attempts, particularly discussing self-mutilation as particularly discussing self-mutilation as a way of dealing with suicidal ideation.a way of dealing with suicidal ideation.

• Although many self-mutilators may not be Although many self-mutilators may not be or become suicidal, it seems many female or become suicidal, it seems many female suicide attempters also self-mutilate.suicide attempters also self-mutilate.

• In contrast to a self-harm continuum, this In contrast to a self-harm continuum, this research suggests a repetitive, wave-like research suggests a repetitive, wave-like patternpattern

Implications for Implications for treatmenttreatment

• Importance of partnershipImportance of partnership• Awareness of power dynamicsAwareness of power dynamics• Realisation that abuse likely, but Realisation that abuse likely, but

may be too painful to deal withmay be too painful to deal with• Assistance to find other ways of Assistance to find other ways of

recovering a sense of power e.g. recovering a sense of power e.g. support to leave a destructive support to leave a destructive relationship, prosecute an abuserrelationship, prosecute an abuser

• Non-reinforcement (by medical staff) Non-reinforcement (by medical staff) – matter of fact attitude– matter of fact attitude

Key features of successful counselling/therapy:Key features of successful counselling/therapy:•an empathetic counselloran empathetic counsellor•a sense of control/partnership in the counselling a sense of control/partnership in the counselling processprocess•feeling listened tofeeling listened to•not feeling like a burden (cf to talking to not feeling like a burden (cf to talking to family/friends)family/friends)•feeling the counsellor could relate– similar feeling the counsellor could relate– similar demographicsdemographics•feeling that the counsellor genuinely caredfeeling that the counsellor genuinely cared•feeling the counsellor could be trusted –feeling the counsellor could be trusted –particularly important issue for women who felt particularly important issue for women who felt betrayed by others including parents and betrayed by others including parents and previous counsellors.previous counsellors.

Implications for Implications for treatment:treatment:

• Importance of partnership in the Importance of partnership in the therapeutic processtherapeutic process

• Awareness of power dynamicsAwareness of power dynamics• Realisation that abuse likely, but may be Realisation that abuse likely, but may be

too painful to deal with immediatelytoo painful to deal with immediately• Assistance to find other ways of recovering Assistance to find other ways of recovering

a sense of power e.g. support to leave a a sense of power e.g. support to leave a destructive relationship, prosecute an destructive relationship, prosecute an abuserabuser

• Non-reinforcement (by medical staff) – Non-reinforcement (by medical staff) – matter of fact attitudematter of fact attitude

Conclusion:Conclusion:

• Although distinct behaviours in Although distinct behaviours in terms of intent and lethality, there terms of intent and lethality, there are clear links, in particular, using are clear links, in particular, using self-mutilation as a way of dealing self-mutilation as a way of dealing with potential suicidality.with potential suicidality.